Diagnosis and Procedure Coding Resources (2024)

FAQs

What are the 5 main steps for diagnostic coding? ›

The National Center for Health Statistics ICD-10-CM Browser tool is here https://icd10cmtool.cdc.gov/ This user-friendly web-based query application allows users to search for codes from the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and provides instructional information ...

Medical records used for procedural coding can include any or all of the following: encounter form, history and physical report (H&P), progress notes, discharge summary, operative report, pathology report, anesthesia record, and/or radiology report.

ICD-10 Clinical Modification (ICD-10-CM): Used by all providers in every healthcare setting; codes for diagnoses; developed and maintained by the Centers for Disease Control & Prevention (CDC), National Center for Health Statistics (NCHS).

CPT® Books & Products

Current Procedural Terminology (CPT®) code books are an integral resource for medical coders and coding students in the U.S. CPT codes offer health care professionals a uniform language for coding medical services, which streamlines reporting and increases accuracy and efficiency.

What is an example of a procedure code? Let's consider an example of a medical procedure code for insurance: CPT code 99213. This code represents an Evaluation and Management (E&M) service provided by a physician or qualified healthcare professional.

1. International classification of diseases (ICD) These are diagnostic codes that provide a standardized way of describing the causes of injury, illness, and death. This code was established in the 1940s and comes from the World Health Organization (WHO).

ICD-10-CM is used for medical claim reporting in all healthcare settings and is a standardized classification system of diagnosis codes that represent conditions and diseases, related health problems, abnormal findings, signs and symptoms, injuries, external causes of injuries and diseases, and social circ*mstances.

What is the diagnosis coding method? ›

Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification. In medical classification, diagnosis codes are used as part of the clinical coding process alongside intervention codes.

Action 5.

Aligning the diagnosis codes with the procedure codes to ensure medical necessity is being evidenced is the next action that must be performed by professional medical coders.

The steps of the diagnostic process fall into three broad categories: Initial Diagnostic Assessment – Patient history, physical exam, evaluation of the patient's chief complaint and symptoms, forming a differential diagnosis, and ordering of diagnostic tests.

5 Learn from others. A fifth strategy to ensure accurate coding and documentation is to learn from others who have more experience or expertise in coding and documentation.